Affordable Care Act & Ryan White: Educate and Assist Your Clients

Ryan White clients need to be prepared for how ACA might change their health insurance coverage--be it Ryan White, Medicaid, or private health insurance. Specific issues to address include changes in eligibility screening, costs, and providers clients can go to for care. In turn, case managers and benefits counselors need to be trained in order to effectively assist Ryan White clients in getting ready for and managing change.

See HRSA HIV/AIDS Bureau guidance explaining how Ryan White service categories can be used to support Marketplace outreach, benefits counseling, and enrollment activities for Ryan White clients (for enrollment in private health insurance plans and Medicaid).

Below are key areas to consider when it comes to educating and assisting clients with ACA changes. Keep in mind that many of the mechanisms for educating and helping clients will be implemented in Marketplaces. As such, Ryan White agencies need to make sure their services and issues are fully and accurately addressed in Marketplace websites, eligibility screening systems, and patient outreach, education, and enrollment.

Develop a Transition Plan

Ryan White grantees and providers can prepare for ACA and assist clients by reviewing their current client caseloads, projecting potential changes in client needs, and then developing a plan of action for educating their clients and staff. Key steps might include:

Assess Current Client Population. Review client-level data to determine the income levels of your clients in relation to the federal poverty level. This information can be useful in determining, for example, how many and which clients will need education on specific insurance changes. Data can be used when establishing contracts with health plans and Medicaid managed care organizations, which will want to know the potential number of new clients your caseload will bring to their networks.

Establish Connections to the State Marketplace. Eligibility and enrollment systems (websites and enrollment assistance programs) have been established in Marketplaces. Ryan White programs may want to sign up and get training to be Certified Application Counselors (CAC) (in states operating as federally-faciliated or state partnership Marketplaces). Access training resources for assisters.

Prepare Your Staff. Educate all staff (clinical, administrative, clerical) on changes around eligibility, billing, referrals, etc. See HRSA HIV/AIDS Bureau information on how Ryan White can support outreach, benefits counseling, and enrollment activities as well as provide premium and cost-sharing assistance for private health insurance and Medicaid.

Educate Clients on Changes. See the next section on educating your clients.

Educate Your Clients: Insurance and Enrolling

Under ACA, coverage options are expanding. Some states are expanding Medicaid. Some are not. All states have new options for purchasing individual and small-group policies. Clients need to understand issues such as new eligibility requirements, possible costs they may face, how to pick a plan, and consumer rights and responsibilities. Below are key topics likely to have particular interest to Ryan White agencies and clients--and resources to dig deeper on each.

Understand Changes in Current Coverage. A significant number of Ryan White clients will be enrolled in public and private health insurance, providing them with a new source of coverage. Many will be eligible for assistance to help pay for the cost of coverage. In some cases, Ryan White will be able to continue to provide support for necessary services that are not covered by other insurance. Learn more about the technical details. See updates in the HRSA HIV/AIDS Bureau webpage Ryan White & the Affordable Care Act: What You Need to Know. Keep abreast of Medicaid and ACA on the HHS/CMS Medicaid and ACA webpages and Kaiser's Medicaid pages.

Get Help Selecting a Plan. Many Ryan White clients will transition to either Medicaid or individual health plans. Over time, some clients will transition back and forth between Medicaid and individual coverage as their income eligibility changes. Clients need to learn how to review, compare, and select a health plan. Even though all plans will be required to offer essential health benefits (EHBs), skillful comparison shopping will be crucial as the specifics of coverage/benefits will likely vary from plan to plan. Ryan White clients that want to keep getting care from their current providers need to pick a plan that includes that provider in the health insurance plan's network. Providers that assist clients in picking a plan need to follow certain procedures in order to avoid conflict of interest. Access resources on Enrolling and Accessing ACA Health Coverage, including materials specifically designed for Ryan White consumers.

Understand Tax Credits and Subsidies. Federal tax credits and cost-sharing subsidies are available to certain individuals who purchase insurance on the Marketplace. The goal is to make health insurance affordable to lower income individuals and families.

Tax credits/subsidies:

Are available to individuals who have incomes between 100% and 400% of the federal poverty level. (More specifically, premium tax credits are available for eligible individuals with household incomes between 100-400% of the federal poverty level, while cost-sharing assistance is available for eligible individuals between 100-250% of the federal poverty level. Tax credits and subsidies are calculated in relation to silver level policies.)

Are available to individuals whose employer-provided coverage is not affordable (defined as costing more than 9.5% of income) or does not have an Actuarial Value (AV) of at least 60%.

Are not available to persons who are eligible for public insurance programs (Medicaid, Medicare, CHIP, TriCare).

Understand How to Use Insurance Wisely. ACA brings new rights and responsibilities. Notable responsibilities include paying for coverage (e.g., monthly premiums, co-pays) and filing a tax return in order to quality for tax credits and subsidies. Rights include access to coverage regardless of pre-existing conditions and other measures. Consumers also have certain rights and responsibilities when it comes to working with a health plan to gain access to certain services, like specialty medications, including, if necessary, filing an appeal about a health plan's decision.

Educate Your Clients: Changes in Care

Clients also need to understand that the health care delivery system is changing in terms of the methods used to improve quality while managing costs.

Care Delivery. Models of care are designed to improve coordination of services, enhance quality, and manage costs. For example, a Patient Centered Medical Home (PCMH) is a health care setting that facilitates partnerships between patients and their physicians. Care is facilitated by registries, information technology, health information exchange, and other means to assure that patients get needed care in a culturally and linguistically appropriate manner. Managed care involves delivery of care using techniques to enhance quality and control costs, like use of a specific set of providers and review and approval to manage use of services. Most Medicaid services are delivered under Medicaid Managed Care.

Health Information Technology. Health IT helps providers better manage patient health through secure use and sharing of health information, such as Electronic Health Records. Access these Health IT resources and videos for patients and families explaining the benefits of information technology in health care, protection of privacy and security, and more.